Nicole Casto was unhappy with the way she looked and determined to do something about it. A year of breast-feeding had taken a toll, she said, so after her tax refund check arrived in June, the 19-year-old single mother underwent breast implant surgery performed by plastic surgeon Barry J. Cohen in his Rockville office.

"My family was upset that I was so young," said Casto, who lives in Woodstock, Va., and works as a waitress. "But I explained to them that it was about being confident," said Casto, who said she is "very pleased" with the surgery.

For decades, plastic surgery for teenage girls meant one thing -- a nose job, frequently performed during the summer between high school and college. While rhinoplasty remains the most common cosmetic operation for teenagers, doctors are performing an increasing number of procedures such as breast implants, liposuction and tummy tucks on young women like Casto and even girls as young as 14.

The enormous popularity of reality TV shows such as "Extreme Makeover," "The Swan" and MTV's "I Want a Famous Face," as well as an explosion of Web sites that extol the virtues of cosmetic medicine, has fueled the desire of adolescent girls to alter their bodies permanently, and they are finding more surgeons willing to oblige them. Breast implants and liposuction are now bestowed by parents as graduation or birthday gifts. Some doctors say they have performed breast augmentations on baby-boomer mothers and their teenage daughters.

Critics say that teenage girls, who tend to be both obsessed and dissatisfied with their looks, are too young and shortsighted to understand the implications of surgery, particularly the risks that implants may pose and the long-term maintenance they require. Among them are the possibility of rupture or permanent scarring, the need for periodic operations to replace or remove the devices, potential interference with breast-feeding and mammography, and unresolved questions about their long-term safety.

"Having cleavage may be the most important thing when you're 18, but it's not when you're 25," said Diana Zuckerman, president of the National Research Center for Women and Families, a nonprofit Washington think tank.

A Recent Boom

In the past few months, several physicians groups have warned teenagers and their parents against resorting to major surgery as a quick fix for popularity or self-esteem.

From 2002 to 2003, according to the American Society for Aesthetic Plastic Surgery, the number of girls 18 and younger who got breast implants nearly tripled, from 3,872 to 11,326. Among all age groups, cosmetic implants have skyrocketed in popularity, according to the American Society of Plastic Surgeons. Last year, according to the ASPS, about 247,000 women got implants for augmentation, compared with 32,000 in 1992.

Although cosmetic surgery remains most popular in other cities -- especially Miami, Dallas, Los Angeles and New York -- eight plastic surgeons who practice in the medically conservative Washington area say they are seeing more teenagers than ever.

"I've seen a huge rise in the number of girls" seeking implants, said McLean plastic surgeon Csaba L. Magassy, who has been in practice for 30 years. In the past year, Magassy estimates, he has given breast implants to about 25 teenagers, most of them 18 or 19, a fourfold increase over a few years ago.

Despite the growing popularity of implants, most teenagers who undergo the surgery are reluctant to talk about a procedure that is easily stigmatized as self-indulgent. A few teenagers who have talked about their decision to get implants have received wide attention.

Several teenage girls who had cosmetic surgery in the past year requested that their names be withheld from this story. One of Magassy's recent patients, a 19-year-old student at Salisbury University in Maryland, said she had been seriously considering implants since she was 15. Unhappy with her 34A bra size, she said she did not like the way her clothes fit.

"My mother and I talked about it, I had money saved, and I just wanted to do it," said the student, whose family lives near Annapolis. She said her parents paid part of the $6,700 fee as a reward because she received college scholarships. "I'm just a lot happier" wearing a 36C bra, she added. "I think a lot of girls think about plastic surgery."

Some of Magassy's patients undergo multiple operations, acquiring smaller noses and bigger breasts at the same time. "That's a popular combination," he said. Stephen Greenberg, a New York surgeon, said that of the 100 teenage girls to whom he has given implants in the past year, about 20 had an accompanying tummy tuck or liposuction.

To Cohen, Casto's surgeon, the dramatic increase in adolescent patients reflects cultural changes that have normalized plastic surgery.

"There's a generational difference," said Cohen, who estimates he has performed breast augmentations on 20 older teenagers. Teenagers, he said, tend to be more open about, and accepting of, cosmetic procedures than their parents are.

Other procedures that have become more popular among teenagers are liposuction and chin implants, which are sometimes performed at the same time as nose jobs. Although some surgeons say they perform liposuction on girls who have lost a lot of weight, others, including Magassy, are reluctant. "They think it's a quick fix and then they're back where they started within a year," he said.

Questions of Maturity

Although there is no prohibition against performing implant surgery on patients younger than 18, some surgeons say they are reluctant to do so in part because girls may still be growing. Sometimes doctors will perform the surgery in cases where one breast is markedly larger than the other or in an older teenager who has no breast development.

"At 18, girls really don't know what they're doing," said Scott L. Spear, president of the ASPS and the chief of plastic surgery at Georgetown University Hospital. Many do not "realize it's more than just having your ears pierced."

Surgeons say they make decisions about whether to operate on an individual basis and try to ensure that teenagers, like their adult counterparts, are appropriate candidates who have realistic expectations. That means weeding out a girl who wants surgery to please someone else, who is counting on surgery to change her life, or who has a deep-seated psychological problem, such as an eating disorder. Surgeons say they tend to subject adults to similar but less intense scrutiny, assuming they are independent and less naive.

Greenberg said he tries to assess how mature teenagers are. He said he turns away those whom he considers too young or those "who say 'I want to look like Britney Spears' or 'I want to be a D cup so I can go out with more boys.' "

Zuckerman said she believes many surgeons tend to gloss over the risks -- which most teenagers do not want to hear about anyway. "Some teenagers sound mature when they're not," she said, "or know the right things to say. You basically have a young girl being reassured by her doctor."

Many doctors say they are reassured when a teenager is accompanied by her mother because it allows them to assess the degree of parental support -- or opposition. Frequently, surgeons say, parents seem unenthused but resigned. "In some ways, it's no different than any other entitlement," said Spear, the father of a teenage daughter and two college-age sons.

Crystal Mast said she told her mother, a nurse, that she was "determined" to get implants after she graduated from high school in June. Mast, 18, who lives in East Islip, N.Y., said she decided the surgery was safe after searching the Internet and booked a consultation with Greenberg, who had been recommended by customers at the Victoria's Secret lingerie store where she worked. After accompanying her to the appointment, Mast said, her mother agreed to loan her about half of the nearly $7,000 surgical fee as a graduation present.

Now that surgery has increased her breast size from an A to a C cup, Mast said, she no longer feels self-conscious about how her clothes fit or in comparison to her more developed younger sister.

Medical Issues

Maturity is only part of the equation, experts say, because of persistent, unresolved questions about the long-term effect of breast implants. In the past 15 years, the devices have been the subject of furious controversy over their safety, mostly involving silicone-gel-filled implants. The Food and Drug Administration has banned the widespread use of silicone-gel implants because of unanswered questions about their safety, but permits the use of saline-filled implants, which have a silicone shell. Both types are the subject of ongoing FDA studies.

Three years ago as a 19-year-old student at Baylor University in Texas, Kacey Long got implants because she wanted to look like Julia Roberts playing Erin Brockovich in the hit movie. Many of her classmates, Long said, had received implants as high school graduation presents.

Her parents strenuously opposed surgery, but Long told them she was going to have it done anyway. Her surgeon agreed to take half his $4,500 fee in installments, and a friend's mother, who worked for the doctor, reassured her that none of his patients had ever complained of problems.

Her D-cup implants were so big, she recalled, that she "looked like a porn star."

A few weeks after her surgery, Long said, she began experiencing shooting pain in her arms, followed by intense joint pain and crushing fatigue. She had trouble getting out of bed and spent months consulting doctors who told her they did not know what was wrong.

Last year a specialist in Dallas told her she had rheumatoid arthritis, suggested her implants might be responsible and recommended their removal. Her parents took out a $6,400 loan to pay for removal surgery. Since then, Long said, her health has improved.

Although many women continue to believe their implants made them sick, no scientific link has been conclusively established with autoimmune diseases such as rheumatoid arthritis, according to the FDA.

But the agency warns in a 2004 handbook for patients that "most women with breast implants will experience local complications" including pain, hardening and rupture. Recipients "should be prepared for long-term follow up, reoperations to treat complications and personal financial costs." Less common complications include numbness, infection and blood clots.

A 1999 report by the Institute of Medicine found that implants can interfere with breast-feeding, as well as mammography, by obscuring part of the breast, potentially resulting in delayed cancer diagnoses. Mammograms also can rupture implants, requiring their removal.

The FDA Web site features graphic photos of complications and notes that 45,000 augmentation patients had their implants removed last year. Removal, the FDA warns, could result in "undesirable cosmetic changes" such as permanently wrinkled, dimpled or puckered skin.

Magassy said that most teenagers who consult him are "so frightened" that they do not ask any questions. During the initial appointment, he said, he outlines the risks and assures patients that implants "are a very simple procedure and if you don't like it, you can take it out."

Psychologist Ann Kearney-Cooke, a visiting scholar at Columbia University who studies girls and body image, said the increase in cosmetic surgery among adolescents reflects a pernicious trend that pervades popular culture: the glorification of rail-thin, large-breasted women. It is, she notes, an unnatural body type rarely achievable without surgery.

"Kids spend a lot of time in chat rooms and they're bombarded by the media with these unrealistic images," Kearney-Cooke said. "When you're a teenage girl, there's this whole myth of transformation that's very powerful: namely that cosmetic surgery can transform your looks and your life.

"It's as though the question 'Who am I?' has been replaced with 'What image do I want to project?' "

Kacey Long, 22, of Ennis, Tex., holds one of the implants she had removed after they caused severe complications, including intense pain and fatigue.Crystal Mast, 18, of East Islip, N.Y., got breast implants as a high school graduation gift to herself and says she is happy with the outcome.